Guidelines - Sonography in hypotension and cardiac arrest (SHoC)

Authors: Özlem Dikme, Attending

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

The use of point of care ultrasound (PoCUS) in Emergency Medicine and Critical Care has been introduced as an initial widespread management tool during undifferentiated hypotension and cardiac arrest by the IFEM Ultrasonography study group via a panel created by internationally recognized leaders specializing to provide an international environment for identifying possible etiology and directing resuscitation. At the same time, the protocol aims to minimize the interruption of the ongoing resuscitation. Protocol developed as a hierarchical model with expert opinion based on published protocols for disease incidence and medical literature and a practical checklist, defined as 4F, has been made.

4F: Fluid, Form, Function, Filling.

The protocol recommendation identified Core, Supplementary, and Additional views for both undifferentiated hypotension and cardiac arrest. Core views must performed routinely for all patients. Supplementary views must performed for all patients where this would likely add further information without delaying ongoing critical care. Additional views must performed when clinically indicated according to the specific clinical circumstances.

Core views on undifferentiated hypotension consist of basic cardiac views (pericardial fluid, cardiac form –size and the shape of chambers (small, normal, large and right to left ventricular size ratio) - and ventricular function –contractility and valves opening status-), lung views (pleural fluid and B-lines for filling status) and IVC views for filling status (dilatation or collapse).

Core views on cardiac arrest are limited to cardiac views and must be performed during the rhythm check pause in chest compressions, without causing prolonged interruption in chest compressions. Assessment has been defined as a team work, and it has been suggested to take an evaluation without interruption by preparing the ultrasound machine prior to patient arrival (if time permits), performing the scan during breaks in CPR and reviewing the images during CPR. Lung views and IVC views are recommended as supplementary views.

The catch-phrase of the protocol is “one size fits”

ShoC Protocol-Hypotension

Core views

Cardiac view

Subxiphoid and parasternal long axis windows

Pericardial fluid, cardiac form (small ventricular size or large dilated chambers, right to left ventricular size ratio), ventricular function (contractility and valves opening)

Atkinson P et al. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM 2016:1-12.